Provider Demographics
NPI:1174500862
Name:RUSSO, TRINA MARY (DPM)
Entity Type:Individual
Prefix:MRS
First Name:TRINA
Middle Name:MARY
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39090 GARFIELD RD
Mailing Address - Street 2:STE 108
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-4093
Mailing Address - Country:US
Mailing Address - Phone:586-779-8600
Mailing Address - Fax:586-779-2019
Practice Address - Street 1:20967 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-779-8600
Practice Address - Fax:586-779-2019
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITR001571213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2760454Medicaid
MI480E020980OtherBS MICH
5505057OtherBS MI
0M71310007Medicare PIN
5505057Medicare ID - Type Unspecified
U19342Medicare UPIN